Lessons From an Unlikely Land – Reflection From the Recent Trip to Cuba by STFM

The 1966 AMA Report of the Ad Hoc Committee on Education For Family Practice (aka “The Willard Report”) affirmed an AMA House of Delegates assertion “…that family practice is important for optimal health care…” while also expressing concerns over the adequacy of the future supply and preparation of the family practitioner. The report argued “that there is a need for a new kind of specialist in family medicine, educated to provide comprehensive personal health care…”  soon thereafter, in 1969, the 20th major specialty, “Family Practice,” was born to great promise and hope.

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Richard Streiffer MD    University of Alabama

 

Today, despite compelling and robust international evidence of the importance of a well-trained, accessible, and ample family physician workforce to the health of a population, we remain well short of that goal in the United States. I believe that many family physicians feel a sense of collective disappointment in this failing, and clearly many are dissatisfied with the narrowing scope and role of the family physician. Many are frustrated by the perception of the collective failure of family medicine to have a greater influence on the nation’s health  as envisioned at our discipline’s launch.  

Still, family physicians aspire to the role which Ian McWhinney clearly laid out his classic Textbook of Family Medicine, where he said that the comprehensive family physician:

  • sees every encounter as an opportunity for prevention
  • sees himself or herself as part of the community-wide network of supportive health care agencies
  • views his or her practice as a “population at risk”
  • visits patients in their homes and “should share the same habitat as their patients” 
  • is a manager of resources.

Elsewhere around the world, this model of the comprehensive, familiar, accessible, prevention- and community-oriented family physician is not only alive and well, but is fundamental to health systems, most of which have better outcomes than here. 

In January 2020, 25 STFM members spent a week in Havana, Cuba, where we visited one such system—the resource-frugal health care system that the Cubans have built is admired around the world for its achievements. A major motivation in visiting Cuba was to see a model where the family doctor is central and deeply inculcated into the very design of the system. 

During our week, we visited and had talks and conversations at numerous representative facilities in the greater Havana area, including a family doctor/nurse consultorio, a polyclinic, a maternity care specialty hospital, a maternity home, a diabetes specialty care center, Centro de Investigación y Desarrollo de Medicamentos (CIDEM – Cuba’s Center for Drug Research and Development), Escuela Nacional de Salud Pública  (ENSAP – the national school of public health), the Facultad Manuel Fajarod campus of the Universidad de Ciencias Médicas de la Habana (The University of Medical Sciences of Havana), and Escuela Latinoamericana de Medicina (ELAM- the Latin American School of Medicine). We also experienced the culture and values of this fascinating Caribbean land, one that at times seems stuck in the 1950s, yet whose people are happy, positive, appreciative of our presence, and have achieved so much not just in medicine, but in science, music, arts and the humanities. 

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To understand the health achievements in Cuba, it’s critical to appreciate that the “developing country” conditions—illnesses and disparities of access to care that characterized the country at the time of the Cuban Revolution in the middle of the 20th century—have been eliminated. Today, despite economic and political challenges, the overall health measures of the Cuban population are near to, and in some areas above that of the United States, and all achieved at a fraction of the per capita costs.  

How have they done this? First, health care is accessible and guaranteed for all, and prevention is first and foremost to their method. Public health and medicine, as well as attention to social determinants of health, are largely integrated compared to the United States, where the fields have largely pursued separate tracks in training and practice. In addition to these principles that guide them, the Cubans are able to articulate clear priorities that drive their resources, attention, and approach. For example, virtually every health professional we met talked about the importance of prevention and of the role of the family doctor, and how pregnant women and their babies followed, closely by the growing elderly population, are at the top of their priority list.  

Perhaps most fundamental to their success has been the foundation provided by the network of the neighborhood-based family doctor-nurse consultorio dyads. Each family doctor/nurse pair lives in a neighborhood where they care for a defined population that they can describe in some detail at the drop of a hat. They use population health methods to conduct risk stratification for their patients, and track their patients with simple, low-tech techniques like daily logs, family (paper) charts, manual screening registries, and home visits. The family doctors are in turn supported through a team of health professionals that includes an epidemiologist based out of the larger hub called the polyclinic. These polyclinics are served by general and specialty hospitals, and a series of subspecialized clinical and research institutes. Throughout the system, the role and importance of the family doctor for implementation and follow-up of any plan is reinforced. 

One of the other more remarkable institutions we visited is ELAM—the Latin American Medical School in Havana—where some 100 US citizens are studying medicine along with thousands of other young people mostly from developing countries from around the world. The Americans do so at no cost to themselves, with only the expectation that they return to their home and serve as physicians in communities with a need. We were privileged to meet with a group of these US students over dinner and learn how unique and special they are. Mostly underrepresented in medicine students, largely from economically disadvantaged backgrounds, 100% fluent in Spanish, predominantly women, disproportionately interested in family medicine careers, and well trained in public health, community involvement in health care, and low-tech, patient-centered care, they are admirably committed to the principles of population health and returning to practice in an underserved community of the United States.  

Most fascinating, this diverse group of Americans is studying in Cuba by choice. Few of them even considered or applied to US medical schools, opting purposefully for the Cuban model out of conviction of its superiority for their future service in communities of need. By training side by side with Cuban medical students and living and working in this system, these Americans are experiencing firsthand the value of the family physician-nurse team’s knowledge of their patients and the neighborhood influences; of the role of the community assessment and home visits; of the potential of prevention and lifestyle change; of how to judiciously use precious resources and a low-tech approach; and of systematic data collection to inform population-oriented priorities.

The burning question for me throughout the trip was “Are there lessons here that we might apply back home?”  Mind you, there’s no delusion here, though at times we were admiring, and perhaps a bit euphoric and somewhat envious. We all knew that this was Cuba—that quirky little embargoed island just off the coast of Florida. Our size, political, and cultural differences from Cuba are significant, so that adoption of a system like theirs is neither realistic nor advisable for the United States. Yet, there are lessons to learn from the principles upon which their successes are based, the most important one being the value of the family doctor to a health system and its ability to improve population health. 

Suggested Reading 

Bhardwaj N, Skinner D. Primary Care in Cuba: considerations for the US. J Health Care Poor Underserved. 2019;30(2):456-467.   https://doi.org/10.1353/hpu.2019.0041

Campion EW, Morrissey S. A Different Model—medical care in Cuba.” N Engl J Med. 2013;368(4):297-299.() https://doi.org/10.1056/NEJMp1215226

Gorry C. Your primary care doctor may have an MD from Cuba: Experiences from the Latin American Medical School.” MEDICC rev. 2018;20(2):11-16.

Gorry C. Cuba’s family doctor-and-nurse teams: a day in the life.” MEDICC Rev 2017;19(1):6-9.

Keck C, Reed GA. The curious case of Cuba.” Am JPubHealth. 2012;102.8:e13-e22.

Ladden M, Mende S. Field Notes: c. Robert Wood Johnson Culture of Health Blog. https://www.rwjf.org/en/blog/2015/01/field_notes_whatcu.html. Posted January 29.  Accessed February 27, 2020.

Dwamena A. Why African-American Doctors Are Choosing To Study Medicine In Cuba.  The New Yorker. https://www.newyorker.com/science/elements/why-african-american-doctors-are-choosing-to-study-medicine-in-cuba. Published June 6, 2018. Accessed February 27, 2020.

Frist B. A Look Inside Cuba’s Family Clinics. Forbes.https://www.forbes.com/sites/billfrist/2015/10/07/a-look-inside-cubas-family-clinics/. Published October 7, 2015. Accessed February 27, 2020.

Hamblin J. How Cubans Live as Long as Americans at a Tenth of the Cost. The Atlantic. https://www.theatlantic.com/health/archive/2016/11/cuba-health/508859/. Published November 29, 2016. Accessed February 27, 2020.

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